Provider Demographics
NPI:1619361904
Name:JORDAN, CALEB LEE
Entity Type:Individual
Prefix:
First Name:CALEB
Middle Name:LEE
Last Name:JORDAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:ROSLINDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02131-1000
Mailing Address - Country:US
Mailing Address - Phone:617-363-8614
Mailing Address - Fax:617-363-8929
Practice Address - Street 1:1200 CENTRE ST
Practice Address - Street 2:
Practice Address - City:ROSLINDALE
Practice Address - State:MA
Practice Address - Zip Code:02131-1000
Practice Address - Country:US
Practice Address - Phone:617-363-8000
Practice Address - Fax:617-363-8929
Is Sole Proprietor?:No
Enumeration Date:2015-03-24
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR42492084P0800X
MAT2861742084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry